Risk factors and prevention of atherosclerosis: specific prevention directed to the high-risk patients

The high-risk population strategy of coronary heart disease prevention are not alternatives but complement each other, both being parts of a comprehensive community programme. High-risk persons must be detected through screening and require more individual and intensive protection than persons at lesser risk for whom the population approach provides adequate preventive care. The relative effectiveness of the two strategies may be compared, using data from prospective epidemiological studies. The high-risk strategy alone compares well with a limited population strategy alone but the balance is shifted in favour of the population at large. In practice, it does not matter to compare the two strategies in isolation but to assess their effectiveness in combination; it can be shown that the combined effect is likely to make a major dent in the burden of disease in the population. It used to be thought and hoped that the discovery of new and more powerful risk factors would discriminate more sharply between future cases and non-cases of coronary heart disease and thus concentrate the majority of new events in a minority of the population. An attempt was made to show that new advances will add to the preventive potential inherent in risk factors but are not likely to identify future victims of the disease with such precision that the high-risk strategy would eventually supplant the population strategy. Instead, new screening strategies must be developed to detect and protect to the greatest possible extent all the risk carriers who are scattered, in terms of single and multiple risk factors, all-over the population. A major responsibility for the effectiveness of the high-risk strategy is carried by the practicing physician, to select the best treatment for individuals and their families and to encourage adherence to a new life style, as well as compliance with drug therapy, if indicated.